Fair Hearing Decisions

DHA Case No. HMO 203704 (Wis. Div. of Hearings and Appeals January 25, 2022) (DHS) ↓ Download PDF A power wheelchair must be approved as medically necessary before Medicaid will pay for it, a determination that includes factors such as being not duplicative of other services and being cost-effective compared to alternatives. In this case, […] Read more

DHA Case No. MGE 203510 (Wis. Div. of Hearings and Appeals March 9, 2022) (DHS) ↓ Download PDF Income is not available if the individual lacks the legal ability to make it available for support and maintenance. In this case, the petitioner was on hospice and totally incapacitated, had no POA or guardian, her marital […] Read more

DHA Case No. MDV 204093 (Wis. Div. of Hearings and Appeals March 24, 2022) (DHS) ↓ Download PDF A divestment penalty does not start until the date a Community Waivers applicant requests a waiver program, meets the functional screen criteria, and meets all other Medicaid eligibility requirements. In this case, the petitioner—represented by a lawyer—divested […] Read more

DHA Case No. FCP 205395 (Wis. Div. of Hearings and Appeals August 16, 2022) (DHS) ↓ Download PDF If agency error causes an unreasonable delay in an individual’s enrollment in Family Care, DHS may backdate enrollment. In this case, the petitioner applied for Community Waivers for both spouses on April 20, but enrollment did not […] Read more

DHA Case No. BCS 204450 (Wis. Div. of Hearings and Appeals March 29, 2022) (DHS) ↓ Download PDF In general, all taxable gross income is counted when determining eligibility for BadgerCare Plus, including Social Security income. In this case, the petitioner deposited his Social Security into an ABLE account. ALJ Beth Whitaker found that the […] Read more

DHA Case No. MOP 204371 (Wis. Div. of Hearings and Appeals May 2, 2022) (DHS) ↓ Download PDF A person must be a resident of Wisconsin to receive Medicaid benefits, and residency ends if another state determines the person to be a resident for its own Medicaid programs. In this case, the petitioner applied for […] Read more

DHA Case No. 204650 (Wis. Div. of Hearings and Appeals May 3, 2022) (DHS) ↓ Download PDF A resident alien is generally not eligible for public assistance benefits for five years after his or her date of entry. In this case, the petitioner had entered the country less than five years before applying for SeniorCare […] Read more

DHA Case No. MRA 205971 (Wis. Div. of Hearings and Appeals October 17, 2022) (DHS) ↓ Download PDF An ALJ may increase the Community Spouse Income Allowance (CSIA) if either spouse proves exceptional circumstances resulting in financial duress. In this case, although the community spouse had $3,858.22 of her own income, she also had monthly […] Read more

DHA Case No. FCP 206406 (Wis. Div. of Hearings and Appeals November 22, 2022) (DHS) ↓ Download PDF The Family Care Contract prohibits an MCO from denying services that are “reasonable and necessary to cost-effectively support the member’s long term care outcomes …”. In this case, the petitioner asked for a home modification: stairs to […] Read more

DHA Case No. FCP 206000 (Wis. Div. of Hearings and Appeals October 28, 2022) (DHS) ↓ Download PDF To be functionally eligible for Family Care, a person must fall into one of the program’s target groups in addition to needing a nursing home level of care. In this case, the petitioner was 44 and diagnosed […] Read more

DHA Case No. CWA 206149 (Wis. Div. of Hearings and Appeals January 12, 2023) (DHS) ↓ Download PDF The Department must ensure the health and safety of IRIS participants, which it does in part by conducting in-home visits. The IRIS policy manual allows involuntary disenrollment for “health and safety risks that participants are unable or […] Read more

DHA Case No. MAC 205887 (Wis. Div. of Hearings and Appeals December 29, 2022) (DHS) ↓ Download PDF A mailed hearing request is considered filed on the date of the postmark or the date DHA actually receives it, whichever is earlier. In this case, the petitioner mailed the request, but there was no postmark and […] Read more

DHA Case No. CWA 206378 (Wis. Div. of Hearings and Appeals December 5, 2022) (DHS) ↓ Download PDF An individual is functionally eligible for Family Care if he or she needs a “nursing home” level of care, as determined by the functional screen. This level of care includes those who cannot safely or appropriately perform […] Read more

DHA Case No. MGE 201120 (Wis. Div. of Hearings and Appeals April 29, 2021) (DHS) ↓ Download PDF When a Medicaid applicant is the grantor of a trust—even an irrevocable trust—it is countable and available “if there are any circumstances under which payment from the trust could be made to or for the benefit of […] Read more